Critical Condition

Is there hope beyond Hope for rural ambulatory care?

Third in a series looking at serious issues with emergency health services in British Columbia.

If you have a story to share with us about your experiences, send an email to newsroom@castlegarnews.com.

Health Minister Adrian Dix has acknowledged that ambulance services in British Columbia need to improve — but it is something that he has been saying for quite a while.

“As opposition MLAs — back to when I was the health critic for the NDP before 2011 — we made the case that the relationship both between ambulance paramedics and BCEHS [British Columbia Emergency Health Services] … and between communities and BCEHS had to improve,” said Dix.

“As a government, Premier Horgan is committed to improving the ambulance service.”

Dix said that some improvements are already taking place, “We are in the midst of organizing and making improvements to the ambulance service.”

“I think you will see a response, for example, soon in the West Kootenays reflecting that — reflecting the fact that we think we can do better.”

Dix defends the province’s model of ambulance service, preferring B.C.’s system of everything being under one umbrella, over Alberta’s system that is an amalgamation of over 30 contracts.

When asked about comparisons that show that Alberta has more emergency health services per capita and per kilometre, Dix suggested that more doesn’t always mean better.

“Our goal is to have better service, we think the way that EHS [Emergency Health Services] is integrated into the health care system is the way to go … sometimes that means more and sometimes that means better.”

B.C. Forest Safety Ombudsman Roger Harris issued a report last fall calling out what he sees as a rural/urban divide in the level of ambulance services provided across the province.

Dix said, “There are issues with the ambulance services in both urban and rural — some of those issues are different. If an ambulance is off on a call in a given community, the rest of that community in that period can feel quite vulnerable — those are significant issues.”

“I think the forest ombudsperson has done a thoughtful report and we need to respond to it — and we will,” stated Dix, who says to expect improvements in the coming months.

“We have an obligation to respond in those circumstances with the best possible service,” said Dix. He explained, however, that services traditionally supplied by search and rescue organizations will continue on in the same manner.

“It has never been the case that BCEHS paramedics and air ambulances go into areas where it is not safe or practical. But that has always been dealt with in some remote logging operations by the employers. In fact, they are required by the law to provide those services.”

As far as how Dix responds to critics that say that if you live beyond Hope or outside of the lower mainland it feels like you don’t deserve or receive the same level of care: “It’s a point to remember — not so long ago I was one of those critics,” he said.

Dix looks to changes coming in BCEHS to make a difference in rural communities.

“What we are responding to in communities … is a higher level of paramedic training. The whole advent of community paramedicine — which I was an early advocate for — is going to be improving care in communities.”

Castlegar News will be looking further at the idea of community paramedicine later in the Critical Condition series.

He also thinks that the staffing model of BCEHS is one of the things that has to change.

“It used to be that the on-call paramedic was a job that people had in addition to a job, say, in the forest industry. The current model that we have been operating on in recent decades … is a model that is out of step with the times in rural BC.”

“When people say that the service has been inadequate in rural B.C. — I agree with that,” stated Dix.

“That’s why we have to respond with better service than we have had. We have to respond with changing times.”

“Having just arrived here, and having been the critic,” added Dix. “I don’t say that everything is perfect — I think things have to be improved. We are going to start to do that. Your readers are going to see that over the coming months and years.”

Grassroots cries for help

Castlegar city councillor Sue Heaton-Sherstibitoff has been lobbying for better ambulance services for years.

She recently presented a motion to Castlegar’s city council that they join many other communities in endorsing the online petition being put forward by the BC HEROS organization calling on the government to improve the ambulance service.

The petition has been endorsed by about 20 B.C. communities.

“I keep telling people the system is broken — we have a system from the 1970s where every community had a working hospital,” said Heaton-Sherstibitoff.

“For BCEHS to say it is going to take years before the system changes — how many people are going to die in that time?”

She would like to see better air ambulance services for her region as well, noting that a minimum four-hour ambulance trip when you are suffering just adds to the trauma of an already difficult situation.

“The system just isn’t working — there is no golden hour for people anymore,” said Heaton-Sherstibitoff about that first hour after an injury or health crisis that help can make the most difference.

Another concern she has is that ambulances are being tied up transporting non-urgent patients between facilities, she would love to see some dedicated inter-facility transfer ambulances for the area.

“I wonder how many people have actually died in transport?” asked Heaton Sherstibitoff.

“Either open our hospital up 24/7, give us what we need to save the lives of our residents — or put more ambulances here that are fully staffed,” she said.

BCEHS responds

BCEHS and Provincial Health Services Authority executive vice president Linda Lupini is the person who is tasked with steering the organization through any changes that will take place. She has been with the organization for about four years.

Comparisons with Alberta show that B.C. has a lot fewer Advanced Life Support (ALS) ambulances — 28 in this province compared to about 250 in Alberta.

When asked if BCEHS plans to drastically increase the number of ALS ambulances and the Advanced Care Paramedics (ACP) required to staff them, Lupini said that is not in the organization’s plans.

“We look at our call volume and the types of calls we get and the number and frequency across the province and then we staff accordingly,” she explained. “A primary care paramedic (PCP) — and primary care paramedics make up most of our workforce — can respond adequately and competently and so can the emergency medical responders that are one level below PCP to most of our calls.”

She said that calls that you would send an ACP to would include about two per cent of calls designated as highest acuity such as drowning, trauma and breathing problems and in addition there would be less than 20 per cent of other calls that you would want and ALS car at to support the PCPs.

“We are not really concerned about the number of advanced care paramedics with regard to our high acuity calls. In almost all cases when we need an advanced care paramedic or we think it would enhance our response, we can send an advance care paramedic,” said Lupini.

In areas outside of urban centres, however, that would likely require flying them into the site as most ACPs are located in larger cities such as Vancouver.

“We don’t really look at our workforce and say we need more ACPs,” said Lupini. “We look at it and say what are all of the different types of calls we go to, how many are there and how quickly can we get the right care to the patient?”

“You have to look at why you would send an ACP — under what circumstances — and you have to figure out whether you are dealing with the very small percentage of calls which are true trauma calls.”

That model is a difficult one for people like Coun. Heaton-Sherstibitoff to accept.

“They have marginalized us,” she said.

“I would think that rural areas would need a higher level of a paramedic as we have major industry where a lot of serious accidents happen and we live in vast areas where we have to travel to get health care. So to say that they’re going to keep those positions in the bigger centres where they already have more hospitals which are closer — doesn’t make sense for rural B.C.”

“Are rural citizens less important than those in Vancouver? I just feel like if you don’t live in the Lower Mainland, you are treated like second-class citizens. We deserve what they have in Vancouver — we pay our taxes. To say that we don’t need it because the local volume is less is absurd.”

Lupini pointed out that there are ACP paramedic specialists that rotate in and out of the dispatch centre where they can talk to crews on the ground and upgrade and downgrade calls.

“So you are getting an ACP’s eyes on a situation,” she said.

Lupini also said that the need for an ACP to practice their skill set to maintain it is complicated in situations with low call volumes.

“We do not have frequent situations where a patient has had a bad outcome or died because we did not have an Advanced Care Paramedic,” said Lupini.

She emphasized the importance of getting a patient to a trauma centre.

“All the paramedics at a scene can only do what they can do,” she said. “We need the infrastructure, the equipment, the health-care team, surgery and other interventions. The idea that you can do a lot at the scene is not necessarily the case.”

“The best thing you can do as a provincial response is to coordinate your ground crew to get a patient either by helicopter to a fixed wing [airplane] and a fixed wing to Vancouver or a helicopter to a community hospital to stabilize the patient and then decide where is the best trauma centre given the diagnosis,” explained Lupini.

She did agree that the closer you are to a trauma centre, the better off you are.

“It’s fair to say that if you live close to a trauma centre you are probably going to be in a better situation if you are suffering trauma than someone who lives very far away. There’s no doubt about that.”

“If you ask me whether it would be a huge improvement or enhancement to our response to British Columbians to have everybody at an ACP level — I would have to tell you honestly I’m not sure that is true,” she said.

Lupini listed a number of things she thinks are the best way to improve service to rural and remote B.C. They include getting Advanced Care Paramedics in the community paramedicine program, adding more community paramedicine programs, adding permanent part-time positions instead of on-call positions and utilizing technology-enabled health platforms.

Lupini also explained that utilizing more helicopters may not be the best answer for better transportation as in most cases it is necessary to transport a patient farther than a helicopter can fly to get to a trauma centre so more fixed-wing aircraft may offer a better solution.

“If the trauma centres stay the way they are and where they are located in B.C. having more fixed-wing would be a better way to enhance service,” she said.

“The Kootenays are always so difficult because the weather changes so quickly there. That is one of the reasons that when we really looked at it we said we definitely need a fixed-wing because we can do more with a fixed-wing in that area.”

“BCEHS has been looking at rural and remote in a very broad way,” added Lupini. “We want to be creative and innovative in how we respond to some of the health needs in those communities.”